Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Monday, June 22, 2009

The Nubbin

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One need think about the implications of this video only for a moment to understand the essential issue: a system that depends on private insurance is potentially no system at all. That insurers routinely deny coverage for any number of reasons means that, in addition to the forty-seven million who have no insurance, there are potentially millions more who only think they do, despite paying premiums.

Insurance companies do not provide medical care. They collect money, invest it, dole it out when they have no way not to. Even for the so-called "non-profits," it's a money-making business, the basis of which is taking money intended for health care, keeping as much of it as possible for as long as possible, returning to the system as little as possible. If it can also be said of physicians and hospitals that they profit from the ill health of others, at least those entities are providing actual care. If we're serious about real health care reform (and it's evident that the "we" is the populace, but not its elected officials), it ought to be the case that any citizen who gets sick can receive care, regardless of the timing of their illness or where it falls in the fine print. Period. And, of course, the same ought to apply to well-care (assuming we know what interventions actually add to health. As opposed to prophylactic spine manipulations, homeopathy, and other forms of woo.) The criterion for coverage: you exist. Other countries do it; why not us?

This is the central idea, the raison d'etre, of a single payer plan. Same rules for everyone. Guaranteed coverage. No wondering, no legions of people spending dollars intended for health care trying to find ways out of spending dollars intended for health care.

And, taking it all the way, what if this care were not only guaranteed but free (or nearly free) of premiums? So what if certain taxes were raised to pay for it? Wouldn't that be more than offset (or at least evenly offset) by freedom from those premiums? And by the fact that there'd no longer be an unnecessary and very expensive intermediary between people and the care they get?

To me it's obvious. Inevitable, even. Although watching Congress I conclude it won't happen for a few more decades, assuming we still exist by then; and only after a complete failure of the current system. The opposition continues to parade their hand-crafted talking points, designed to scare and distract. There simply are no salient arguments I've heard that make a case for maintaining the intermediary of hundreds of insurance companies, other than what amounts to "we need them because we have them." What good are they adding? What particular and essential need do they fill? For the billions and billions of dollars, intended for health care, that insurance companies make, take, and keep, what do consumers get that justifies their existence? The "public option," they tell us, "is just a way to get rid of insurance companies." And that would be bad, how?

Seriously. Somebody tell me. I can't think of a thing.

And yet, if you listen to our Congresscrowd -- practically all of 'em -- you'd think it's the insurance companies that are responsible for everything that's good about American health care. "The best health care the world has ever known," as one of them recently said, ignoring the price we're paying compared to the rest of the world, the millions with limited access to it, and the fact that we are at the bottom end of most measurable health criteria.

I think it is the essence of the contrary argument. Although, as I've said, were we to go all the way to provide universal coverage under a single payer, taxes would be offset. For those who love insurance companies, there ought to be a way to provide them the option.

Or, if they want the same result without all the paper work, whenever they get sick they could run into their bathrooms and do this.

23 comments:

NE1
said...

I am a little scared at the timing of all this: the rush to single-payer concurrent with the knowledge that health-care run-ups are our only weakness in the future [all the smart economists I read say this].

I think the attachment to insurance companies is that somebody should be watching out for costs, and that they should be fairly consistent if their pool is large enough. I suspect for someone like Aetna, it is. It helps Congress to have something impersonal like a company to argue that things like organ transplants and experimental chemo can't be free to everyone. Robin Hanson always has a fresh, contraflow opinion on health care, even if I don't always agree immediately. I've seen his graph that shows the failure of HMO's to keep costs down after only a few years since their creation, so maybe this isn't a complete answer. I haven't seen too much blowback about the British health services (or Canadian, for that matter), so maybe it's perfectly feasible.

You argue for universal health care by obviousness... I see several things. People are more productive with solid health care--this is the current rationale for businesses providing health insurance. And, some things in life are unfair--birth defects, genetic rolls of the dice [I'm not ready to incentivize genotype-awareness over love], and too-late health science. Are we righting some universal wrong by treating the unfairness? Sounds like a philosophical argument about Justice; maybe that deserves to go into a new Amendment.

For the video, I see a little grandstanding, but I would be more sympathetic if it weren't a hearing about rescinding during the first year of coverage. I can totally believe that people quickly making large claims were willing to bend the truth on their application, however tragic it is that this even happens.

Sorry to go off topic Sid (this seems to happen whenever I comment on your blog[s]) but I thought you might be mildly interested in this story of a London surgeon who does single incision laparoscopy; http://news.bbc.co.uk/1/hi/health/8112724.stm

Reason I'm posting is that the article mentions that he can remove gallbladders in an hour, but I'm sure I read on this blog that you did it in around 12 minutes using your 'mini-chole'?

1.) Why haven't those who so strongly support universal healthcare formed a truly not-for-profit insurance company yet?

They could start by targeting only California, putting their money together as a reserve for all the initial policies, invest it with Goldman Sachs (who, with the governments/tax payers help, will be posting record profits this year)and over the course of a few years this company should be strong enough to return the initial investment back to the philanthropists who started it while continually adding more policy holders.

If this model worked, it would grow on its own, and there would be no need for politicians to force a plan on ~49% of the pop. who are not comfortable with it.

2.) Why does the universal system have to be nationwide immediately?American's would be much more receptive to implementing a system nationwide which has already been proven to work in one state, whether its a private non-profit like above or a state wide universal coverage system.

3.) One last thought. Isn't there something to be said for 100 shady insurance companies battling it out for my insurance business, rather than 1 government controlled by shady politicans in control of the whole deal?

Something die-hard free marketers seem to miss is that employer-based health insurance limits our productivity. Any number of citizens work jobs for which they are overqualified, simply for the health insurance. Otherwise they could focus on their highest and best use. Also a GM car costs more in health insurance than it does in steel. Single-payer health insurance will clearly aid our exports.

NE1: the costs of health care are generated by the care. Insurers do little to control those costs, except in the same way that a single-payer would. In fact, the biggest concern about single payer is that it would be in a stronger position to force providers to accept lower payments. The only difference is the extent to which insurance companies suck money out of the system in ways that medicare does not.

As to the video: it's only a snippet. Prior to that segment were the testimonies of people who'd been denied despite making NO errors or false statements.And, of course, that's the point of universal coverage. You're covered.

P. Thump: 1) they have. It's called medicare.

2) First of all, it's not gonna happen. I'm saying what ought to happen, not what will. And, once again, the model is medicare, which has been in place for decades. It has funding problems, but not coverage problems. There are states, ie Massachusetts that have plans. Unfortunately they are insurance company based, which is why they're in trouble.

3) No. Show me where insurers are "fighting" for your business. They're fighting to keep your money. And the idea that "politicians" would be "in control" is the main disingenuous talking point of the naysayers. As I've said elsewhere, the rules are pretty much established by medicare already. There's less hassle for doctors having care approved in that system than with private insurers. It's just a Frank Luntz talking point, for which people easily fall.

Alex: single incision laparoscopy has been around a while now. An hour is longer than most take for the more typical laparoscopy and, as you said, lots longer than my form of single incision mini-chole. It's not entirely off-topic: such things add cost (robots are even worse) while adding questionable if any value. We're talking about more expensive surgery, the benefit (if any -- we don't know much, yet, about complication rates) of which is cosmetic.

Sam: I agree. And yet it's been demagogued effectively. No one ever said rational arguments will win the day.

Sam, the steel comparison doesn't work out in your favor--surely it's the engineering that should be more costly in America than the raw materials, and the engineering is a prime argument for the healthcare. We don't want to have to be Chile.

It’s official. America and the World are now in a GLOBAL PANDEMIC. A World EPIDEMIC with potential catastrophic consequences for ALL of the American people. The first PANDEMIC in 41 years. And WE THE PEOPLE OF THE UNITED STATES will have to face this PANDEMIC with the 37th worst quality of healthcare in the developed World.

STAND READY AMERICA TO SEIZE CONTROL OF YOUR NATIONAL HEALTHCARE SYSTEM.

We spend over twice as much of our GDP on healthcare as any other country in the World. And Individual American spend about ten times as much out of pocket on healthcare as any other people in the World. All because of GREED! And the PRIVATE FOR PROFIT healthcare system in America.

And while all this is going on, some members of congress seem mostly concern about how to protect the corporate PROFITS! of our GREED DRIVEN, PRIVATE FOR PROFIT NATIONAL DISGRACE. A PRIVATE FOR PROFIT DISGRACE that is in fact, totally valueless to the public health. And a detriment to national security, public safety, and the public health.

Progressive democrats and others should stand firm in their demand for a robust public option for all Americans, with all of the minimum requirements progressive democrats demanded. If congress can not pass a robust public option with at least 51 votes and all robust minimum requirements, congress should immediately move to scrap healthcare reform and demand that President Obama declare a state of NATIONAL HEALTHCARE EMERGENCY! Seizing and replacing all PRIVATE FOR PROFIT health insurance plans with the immediate implementation of National Healthcare for all Americans under the provisions of HR676 (A Single-payer National Healthcare Plan For All).

Coverage can begin immediately through our current medicare system. With immediate expansion through recruitment of displaced workers from the canceled private sector insurance industry. Funding can also begin immediately by substitution of payroll deductions for private insurance plans with payroll deductions for the national healthcare plan. This is what the vast majority of the American people want. And this is what all objective experts unanimously agree would be the best, and most cost effective for the American people and our economy.

In Mexico on average people who received medical care for A-H1N1 (Swine Flu) with in 3 days survived. People who did not receive medical care until 7 days or more died. This has been the same results in the US. But 50 million Americans don’t even have any healthcare coverage. And at least 200 million of you with insurance could not get in to see your private insurance plans doctors in 2 or 3 days, even if your life depended on it. WHICH IT DOES!

jacksmith: I guess I agree sort of with the spirit of your comment, to the extent that we agree about a single payer system. I don't agree with the full throated panic about the pandemic, nor, under any circumstances, with the idea of "seizing" the insurance companies. In fact, it's that sort of rhetoric that the opposition uses to scare people away from the obvious need for a national plan.

NE1 - You mystify me. We should be spending more on health care than on steel when we manufacture a car? I just can't see why because Honda, Hyundai, Toyota etc spend zero per car on health care costs.

I think you know that engineering is planning and testing, the first step in the manufacture of a car, which is followed by production, and that in a successful model production costs dwarf by engineering costs. There are many more factory workers than engineers in US auto operations. Again I'm just totally mystified.

Just like doctors are entitled to make a profit, so are businessmen and insurance companies. Nobody ever said healthcare was a charity.

I agree that our healthcare system should be very similar to our European brothers. I don't mind at exchanging my premiums for taxes (in lieu of premiums).

I do not however agree with the demonization of insurance companies. People hate insurance companies like the hate the IRS, but without both where would we be?

You get what you pay for. People yelp and cry that insurance companies take their money and then refuse to pay claims. For the most part, that's bullshit. If your policy says we pay for A, B, and C, but not for D, and if you then file a claim for D, what do you expect??? If you wanted coverage for D then you should have paid more and bought a policy that covered D. That's the way it is, and until we have something better, live with it.

So en the mean time, if you need surgery and it's not covered by your insurance policy, Sid will do it for free. Oh wait, he won't, because he has to live, just like everyone else. He has to put food on his table just like the guys from the "high school educated" claims processor, all the way up to the high paid executive. It's not like those executives didn't work their ass off to get where they are, just like Sid had to in order to get where he is.

Where we part company, Mike, is here: we agree people are entitled to make a profit. What we don't agree is that insurance companies are useful in any way. It's as if you drive into a gas station, hand a guy who doesn't work there twelve bucks, he keeps two, and pumps ten bucks worth of gas. Without him, you or the gas station guy could pump it and you get twelve bucks worth.

Sure, they have their rules, they pay what they agree to pay. But why are they there? What do they add?

And I never saw an insurance company exec coming to the ER at three in the morning. I don't think they work anywhere near as hard as I did; yet they make five or ten times more than I ever did. Except for the ones that make even more than that. They didn't work anywhere near as hard as I did to get there, nor even close to as hard having gotten there.

And I did lots of surgery for free. And all of it for less every year than the year before, mostly.

Explain why we need insurance companies instead of a single payer. Explain why we're better off having the costs of hundreds of companies inserted between patients and providers. Explain why they ought to profit, to the tune of billions, from money intended to pay for health care when they do nothing to add to the public health. That's the question to which I have no answers.

More is better, works with Insurance Companies just the same as with Cable TV... Lets say you prefer 24-7 Gay Porn, or Mozart, and I like watching reruns of 40 year old Nascar races...with Cable, everyones happy... Single Payers makin everyone watch PBS but its OK cause its "Free"... Myself, I'll pay a little more for the Gay Porn, I mean, Gilligans' Island Marathons...

What do insurance companies add? They level the playing field. Privately purchase medical insurance sucks. It costs a lot, covers little, and excludes many from even being able to purchase it. Group policies however, those which I believe cover the majority of insured Americans, pool the resources of many and give leverage to the people.

First, I'm not a historian, but before people got group coverage through their employers, and either got very ill or had serious trauma, what did they do? I'm guessing, but I'd say a lot of them died because they didn't have acce$$ to expensive medical services.

We spoke about this the other day. If Joe the Plumber (okay, that was a horrible choice of names) gets in a car wreck and goes to the hospital. They treat him. When the bill comes, if Joe has either insurance, or Medicaid/Medicare, then there is a big brother both protecting him by paying the majority of his bills, and also protecting him by preventing providers from charging exorbitant sums of money. The hospital and providers get paid, lets say, $15,000, and Joe's out of pocket is $50 for an ER visit.

Without insurance, those same providers bill Joe $45,000 for the same services. Joe can't pay, the providers put him in collections, Joe has to file bankruptcy, and loses everything.

So there are two questions here. Q: What would be better, insurance as we know it today, or universal healthcare. A: Universal healthcare, without a doubt.

Q: Would you rather have a system based on insurance as we know it today, or a two-party relationship between patients and providers. A: I'll take the financial security of insurance any day.

Reviewing the 78 major companies constituting the well-known Dodge and Cox Stock Fund, I see Health Care has risen to 27%...from the S&P Index which contains only 15%. These health care entities are the usual pharmaceuticals, but major players are WellPoint (Anthem,Blue X, Blue Shield),Cardinal Health, Humana, United Health Group and others. It would seem the guys in the know do not believe in the demise of Health Insurers...There are thousands of paper shuffler jobs at stake, and wiping them all out for a single payer USGov seems to me to be wild dream. Talk to me in a year...I say docs will still be begging insurance companies to let them admit or operate on some poor guy lying on a guerney in the ER....and the single most obvious result of whatever "happens" will be the loss of highly qualified US trained physicians of all types to the ultimate.... "I quit". Like my recent PaloAlto VA experience: "Better learn Tagalog and Farsi to Survive Here." (bumpersticker on Vet car in handicapped lot 6-19-09).

Mike: your arguments strongly confirm why we need universal healthcare, which you then acknowledge. I don't understand you second question, nor the answer. Literally. I don't know what you're asking. But given the first question and answer, the second seems not to matter. Theoretically.

Dr Baldwin: We agree, I think. Whatever form health care financing takes in the future, it seems certain the trend toward paying docs less and making the rules more complicated will continue until a breaking point is reached. For many of us, we got there a while ago. To get it right before the breaking point would require many things, the political will for which is not likely present.

Frankie: it's like recovery. I have to transition back to surgery. First step was to get to the blog; then some medical posts with political ramifications; then, hopefully, I can get back to what I was doing (and found much more satisfying) before. Remember I'm not in the OR any more, so I have to dig through the rubble and ruins of my brain.

Sid, my only gripe is the notion that insurance companies do no good. I believe, that they truly help a lot of people, while I admit this system is not the best.

That being said, We're on the same page as far as universal coverage. I would give almost anything to hear I could pay a specific tax, which increases with income, and that all American citizens would be provided really good healthcare. No American citizen could be turned down based on any condition, and that my sister who is a single mom making $14 an hour gets the same exact coverage I get making $200,000+ this year. I don't mind that I will pay more for my same coverage than she will.

What I think is really said though, is that what I just mentioned is absolutely not what is going to come out of this congress. In that single point, I feel President Obama has let me down.

You see, I have diabetes. If I didn't get coverage through my parents while I was a kit, through student insurance in college, my jobs when working, and through my wife's job over the last several years, I'd be f****d. Nobody is going to sell a diabetic an insurance policy, other than group coverage as I've described.

But I don't think I deserve to die if my wife loses her great job with great insurance. I can't afford the medicine. My wife and I have talked about it, and without some sort of intervention, I'd be dead in less than 6 months. It's not fair.

I could think of some really easy reforms to pass immediately to bring healthcase costs down:

1) go back to making it illegal to advertise prescription drugs. Congress changed the law under pressure from the drug companies on the idea that information needed to get out there. Fine. But now we have Google. So, allow them to post on their homepages announcements of the FDA approving their new meds--but require that each announcement also state all the side effects and complications known to go with it.

Patients will find that information, they'll be informed, and all those horrendous advertising costs will go poof. Not to mention the distortions those ads cause: I was horrified when Remicade was advertised as if it were literally a walk in the park, when taking it was a life-or-death decision for me. The FDA came out with a warning early on that it had caused 126 cases of congestive heart failure--guess who was case #127.

2) Require private insurers to have the same restrictions on pre-existing medical conditions as HMOs. Unless outright fraud can be proved, no more of this going fishing to find any irrelevant thing to bounce a patient once their disease costs too much--it's immoral, unethical, and there's no way it should be legal. It bankrupts doctors and hospitals so that insurance execs can make extra millions.

Let me add quickly, but I am very very grateful that Remicade was an option. I'd have died without it. The thing I'm afraid of is its being overprescribed because the true picture of the cost/potential side effects ratio isn't out there the way it was when it was experimental, when I took it. Then having it get yanked off the market a la Vioxx when too many people suffer from the side effects who weren't expecting them and who didn't realize the choice they were making, and people like me dying because of that.

Speaking of which, I have a daughter with ITP and Vioxx was the only painkiller she could take without risking bleeding to death. And now it's gone.

Hi, I was looking for surgeons' blogs. Anyway, I agree with you. I think though that the proposals being pushed out there are nothing more than another added layer of bureaucracy for the insurance companies (Blue Cross, Aetna, United Healthplan, HealthNet etc.) to skim more profits off the top.

I've written 5 articles about this on my blog. I don't offer solutions --in fact, wish we could have "a worry-free, hassle-free" system, where the doctors could be just that. However, the insurance companies are not going to give up their slice.

You can read one of them here, and get the rest by typing in healthcare under the 'search box' on the upper left.

About Me

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.